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Thursday, September 23, 2010

5.(11-14) Arthritis, My Neck, Fibromyalgia, Tendonitis, Thrombophletibits


Physician's Notebooks 5 - http://physiciansnotebook.blogspot.com - See Homepage
  Major update in process 16 Aug. 2018
In order, Chapter 11, The Skeleton-Muscle System, 12, Dem Bones, 13, Arthritis and finally, Chapter 14 has personal experiences with bony joints.
Acronyms in this Section: ORIF is "operative reduction and fixation", the usual surgical treatment of complex fractures
   PT to walk is "physiotherapy" femur fracture, sometimes referred to in Japan as "rehabiri".
Reynaud Syndrome: Scroll to Chapter 3 or use Search & Find keyboard shortcut Ctrl +F shortcut
 (Note: These chapters are packed with personal experiences; though written somewhat sloppily they are of tremendous value and particular sections should be read carefully and advices paid attention to)
Chapters on Supports & Connections
       Chapter 11. The Skeleton-Muscle System
– is what gets us around. As an 85-year-old, for me the most important health issue, to paraphrase Elton John, is Am I still standin'?  My low back is, practically, falling apart and walking is constantly painful and I need daily 325 mg aspirin and/or 300 to 600 mg acetaminophen and even need to wear a tight girdle. And it caught me flat-footed so to speak. I paid good attention to my heart, brain and other vital organs to achieve healthy longevity but I mostly ignored my bones, muscles and joints. And now because of my not watching my back and neck for 70 years; because of my poor posture and my frequent careless falls, I am near to being incapacitated and only barely still standin'. Then see what happened to me in the below. 
      
  A Fracture: I just had a particular experience with a particular fracture. It was 23 March 2018, and I was on the subway in Tokyo and the train was coming to a stop. Stupidly, I got out of my seat without holding on to anything and just then the train gave a jerk, throwing me to the floor on my arse. I knew it was bad right away because of the pain. With the assistance of other passengers, I was barely able to exit the station and take a taxi to my near-by office. But I was in such a great pain that I had to call my doctor and arrange to be taken to the university hospital. The x-rays showed pelvic fractures, of the left and right inferior pubic rami. And the blood test showed a lot of blood loss. The orthopedist gave me a choice of having an emergency surgery or conservative treatment which means doing nothing for 10 weeks in bed. I chose 10 weeks in bed and finally healed. And this happened because I stood up inside a moving vehicle without holding on. I'm lucky I lived. 
Fat Emboli under Skin: After traumatic fractures it's not unusual for the patient to notice fat emboli to cause small hemorrhage spots under the skin. They are more frightening than they are dangerous; however, one should take aspirin for a couple of weeks in order to prevent more serious emboli. 
Today I give young readers the following advice: Start from childhood (with good posture and avoidance of bad posture study habits). Pay attention to avoiding falls and be sure your home environment has built-in soft landings like Japanese tatami floor or western style soft flooring. I kid you not: take me seriously; more seriously than I took my low back and lower extremities. And never, never ever, stand free (without holding onto support) on a moving vehicle
Chapter 12. Dem Bones
 Here are preventives against fractures and other bone or joint damage: 1) Keep Body Mass Index (BMI) below 25 and get it down to 20 by after age 60. 2) Pay attention to adequate calcium and vitamin D intake. 3) Avoid accident and do not carry too heavy weights. 4) Practice good posture when walking, standing and lying down. When walking, look up and straight ahead; not down except brief glances to watch for tripping objects, and Walk strong! Don't Slouch or Shuffle! When standing, stand straight When lying down, lie mostly flat on back, and stretch and elevate extremities as part of regular lie down exercise; in bed do not scrunch up in fetal position on side. 5) And most important of all, for me recently is that when you are on a moving vehicle never allow yourself to stand free without holding on to support because the vehicle may suddenly jerk and you may be thrown to a hard floor and sustain a difficult fracture as happened to me as happened to me 23 March 2018. 
Chapter 13. Arthritis and Joint & Extremity Pain
The descending order table of topics as they appear in text. You may locate each by search & find or scrolling down.
Arthritis is 
My Hip Joint Osteoarthsritis
Trauma
Abnormal Position Stretch-Joint Pain
Arthritis of the back
OsteoArthritis (a.k.a. Degenerative Arthritis) of Hands, Feet and Larger Joints like the Hip 
Preventives
Reports of Hip Replacement
My left hip-joint total replacement of 4 June 2018
Immune System Arthritis  - Rheumatoid
Crystal Deposition Arthritis – Gout
Infection in Joint
Arthritis after Infectious Disease
Pain of Muscle, Tendon, Bone, Cartilage, Ligament & Blood Vessel
Bursitis and Bursal cysts - Bakers Cyst, Ganglion
Bone Pain
Thrombophlebitis - DVT - Pulmonary Embolism
Reynaud Syndrome
Fibromyalgia
Whiplash Injury Magic Cure!
The Back and its Pains
Lumbo-sacral (Lumbago) and Sacroiliac L-S Pain Disc Syndrome
Inter-vertebral disc hernia
End Note on low back pain - good effect of firm mattress
Warning Against Opioids for Back Pain
Corticosteroid injections
Malingerer and Neurotic
Arthritis is inflammation of joint; it can be from repeated minor trauma; it can be the wear or tear of aging, or an inherited or acquired tendency of an immune system to attack its own joint, or from chemical crystallization in joint, or from infection. Or it can be from bad posture and frequent falls. Acute arthritis causes swelling and redness in the joint, but in chronic arthritis the symptom and sign is deformation and disordered function and eventually debilitating soreness. Any joint may get affected but the hand, foot, knee, hip or back are affected most often. (In my case at age 85, before my left hip-joint replacement, my left hip osteoarthritis reached a point where I almost could not walk on it because of the fluctuating pains; I connect this with my poor low-back care when I was younger and frequent falls)
   My Hip Joint Osteoarthsritis: In my case, I especially developed a bad osteoarthritis of the left hip joint that I first noticed around age 70 and that by age 85 became so painful and noisily crackling that I almost couldn't walk.
And as a result, I had a bad accident on the subway (see my fracture).
Trauma 
Accident or repeated minor bump; any emergencies should be obvious; they involve disruption and bleeding and need inactivity to heal. But although they should be obvious they are often carelessly ignored as I ignored in my case. This is probably the reason my hip osteoarthritis is limited to the left side.
Abnormal Position Stretch-Joint Pain:  Particularly in the knees, holding an extremity in abnormal stretch position too long can result in several days joint pain on movements. In the knee it comes mainly from sitting in train coaches with your feet up and heels on opposite facing seats causing excessive tension on extensor tendons of the knee (straightened knee syndrome).
Arthritis of the back is from lifetime calcium loss and older age low sex hormone levels, from the trauma of falls and also from poor posture. In upper part it leads to the bent cervical-thoracic spine that at worst is dowager hump. To prevent it, stand up straight. In lower part it is caused by vertebrae collapse disc problems and low back pains, and often by too many falls on back.
OsteoArthritis (a.k.a. Degenerative Arthritis) of Hands, Feet and Larger Joints like the Hip is old age-related and is caused by lifetime small traumas as the examples, of the old-age typist's arthritis and ballet dancer arthritis. My left hip arthritis was probably mostly due to accidental falls on left buttock during younger life.
Preventives vary with location. In back problems keep reminding yourself especially when walking "Straighten your back", and sleep on firm mattress face up. Then, as implied above, do not forget a risky profession like ballet dancing, a cause of crippling foot arthritis in old dancer. If you really are good at ballet, and love it, at least retire early (Before age 25). Typewriter hand arthritis should now be obsoleted. And be a bug against falls! In all cases, keep good calcium and vitamin D intake in food.
Reports of Hip-Joint Replacement  The following is a self written report of right and left hip replacement in a woman who had them done in her mid 50's to early 60's because of severe degenerative arthritis. She was about 10 years post menopausal and never took hormones or calcium & vitamin D pills. First the right hip at age 54:
I prepared for the surgery by doing physical therapy. Before the surgery, I donated two units of my own blood in case I needed it. Everything went well during and after the surgery. I spent about 2 weeks at the Rehabilitation Facility, and did a lot of physical therapy there and after, as an outpatient. I had one setback when I took a bad fall on ice about 8 months after the surgery, and even the Surgeon was surprised that no damage was done to the replacement. Right after the fall I was in much pain and the whole area was black and blue for a while. I did continue with physical therapy, and I do aqua-aerobics to this day. After the wound was healed (about 3 months), I was able to go aqua-therapy in a warm pool. It has been over 12 years, and I have no pain or problem with the hip. I was in a lot of pain before the surgery. Now I have no limitations, except that it is easier to get up from the bath tub or floor by turning around and getting on my knees first.
   Eight years later, she had the left hip joint replaced as follows: I had my left hip replacement, but I did not prepare with PT beforehand. Although everything is fine now, this surgery had some complications, as my femur was cracked during the surgery, requiring two cerclage wires. This time rehab was difficult, because I wasn't supposed to put all of my weight on the hip and had to favor the right hip, which had been replaced in 2002. During PT, I noticed it was hard to breathe, and it was discovered that I also had a collapsed lung, which got better right away too. This time, I was in the hospital for almost a month. Both hips are doing great now. I have absolutely no pain and can do anything.
Comment on the Hip Replacements: The reason for the early age degenerative hip arthritis in this case is self reported as follows: "I had fallen hard on my right hip about a year or two before the surgery (and other times) and didn't take care of it. The doctors think that made it turn into arthritis. The left hip was a different pain. It started hurting years later, and would make a cracking sound whenever I stood up." (Ed: She took Calcium carbonate 500 mg and vitamin D 10 microG twice a day for years before needing the surgery. So try very hard not to fall and try to avoid especially the hard surfaces where you may fall, ie, prefer Japanese tatami floor to hard floor) Note on this comment, I (Dr. Stim) would completely agree. 
         My left hip-joint total replacement of 4 June 2018:
As mentioned I developed osteoarthritis of the left hip and symptoms (crackle sounds, pain on left hip on walking, limitation of movement, tendency to accidents) over the next decade; so much so, that by 2018 I could barely walk and had to hobble around using my rolling luggage as support. I had delayed a decision on hip-joint replacement because I had other problems (low back syndrome, undiagnosed soft-tissue stiffness of both lower extremities) but, by March 2018, I was forced into a positive decision because there was no place else to go to allow me to be "still standin'." I visited a very good university orthopedist (Dr. Hideki Fujii, Jikei University in Tokyo) and he scheduled me for the 4 June hip-joint replacement. Then, on 23 March, I had the previously mentioned accident on the subway (due to my osteoarthritis and carelessness) that caused the pelvic fractures. This required 10 weeks of bed rest which worked out just right to allow me to still have my surgery. I was discharged from hospital 24 May "back to square one" and re-admitted 2 June. 
The surgery went as follows: On the night of 3 June, I went NPO (nothing in my mouth; standard for all major surgery) and stopped all medication (I had stopped my daily aspirin on 4 May). At 8:20 I was taken to OR. At 8:30, the anesthesiologist who started my IV was bent over injecting unconsciousness-inducing medication. My next memory was 1 PM in the recovery room. (Between 8:30-1 PM, I was essentially dead. The only difference being, I woke up, which you don't when you die) 
The record revealed that the surgery took about 1 hour. The upper part of the femur and the attached left hip joint was removed and a titanium replacement shaped like the inner part of the femur and the ball of hip joint replaced it, with the titanium rod anchored deeply in the marrow of the upper femur and screws used to fix the ball of the femur in place in acetabulun. The muscle and subcutaneous tissue incision was closed and the operation was completed. Arriving back in my room, I immediately noted that my brain power was completely intact with no loss of memory or other brain function. Also, I noted dramatic reduction of the usual pain in the left hip-joint that I have noted in the year or two with the worsening osteoarthritis, even moving around in bed. The next morning, 24 hours after the operation, although I felt soreness and stiffness at the operative side, I was able with assistance to actually walk although unstably had I been outside the street. However, it was a dramatic difference from before the surgery. Interestingly, the first day or two after the operation, I was able to walk without almost any pain, although still unstably so that I wouldn't trust myself alone. But by the third and fourth day, I actually noted a mild increase in soreness and pain when walking although it was still with much better than before the surgery. Now (this is being written on the 6th post operative day) I am able to walk fairly well with assistance or rolling luggage support. The operative side is sore (day 5) and the stitches are planned to be removed at the 1-week point. I had a low grade fever (37.3-37.9) for the first 4 days, which I was told is normal after the surgery. On the 5th day, my temperature was normal, 36.7. Now, (day 6) I can say that the surgery seems to have been a success and I chide myself that I did not get it done 1 or 2 years earlier. It was as easy as the proverbial rolling off a log. 
Continuing this report now 25 July, 51 days after the surgery and 1 month after hospital discharge, the left hip is fairly perfect for walking. I do occasionally notice a kind of semi dis-location feeling when I sit too firmly on left buttock by just lasts seconds.  At this point, 8th week post op I judge the surgery 100% successful. I can walk again ! Add on, now, 15 Aug. I continue very good result.

Immune System Arthritis  - Rheumatoid
Rheumatoid Arthritis starts at younger age than osteoarthritis; it is more in men. First attack goes weeks and it alarms especially when Doctor says  “Rheumatoid arthritis.” Complaint is ache in hand but it can hit any joint. In finger it involves the proximal joints compared to osteoarthritis, which involves the distal (closer to fingernails). As years pass, various joints are affected with deformity. Some patients have intestinal complaint and nodules of skin; all develop positive rheumatoid factor in blood test. It does not always cripple or seriously affect other organ function. In my observation the worst effect is fear.
I advise youth who gets a doctor’s diagnosis of it to ‘cool it’. When it is time for normal medical check, get tested for CBC and for the rheumatoid factor (RF). If RF is positive, consult a rheumatologist.
Crystal Deposition Arthritis – Gout ("Tsufu"  in Japan)
is attacks of big toe severe pain with exquisite tenderness to touch, and swelling and redness. Mostly in men and occurs after exposure of toe to cooling, as well as positions of feet that cause sluggish circulation (as in prolonged sitting). Coolness and sluggish circulation favor uric acid crystal in small blood vessel of affected joint. Dehydration (in high altitude flight) or excessive exercise promotes attack.
Gout is distinctive; anyone who has suffered one attack will diagnose it from first twinge.
Get blood test to determine uric acid. Ten mg% or higher requires uric acid lowering because of kidney stone risk; 8 to 9 mg%, needs attention to diet (low meat and other purine food) and possibly UA-lowering medicine like Zyloric. Most gout is metabolic inherited tendency to high UA but it can be due to cancer or chemo treatments, also to weight loss or to too much food. To prevent UA stone, drink water, drink water, and more water.
Infection in Joint
In physically active young men, infection in a joint (knee or elbow most frequent) is complication of nearby skin infection, or else it is sex disease gonorrhea. Tuberculosis leads to infection in vertebral body joint which causes severe deformity. These infections drive victim to seek medical care because joint becomes fiery red, swollen, painful and tender.
Arthritis after  Infectious Disease
Virus infection or the bacteria, beta-hemolytic streptococcus, causes transient (days to week) migratory (from one small joint to other) joint pains with fleeting skin rash. The most infamous arthralgia-causing virus is rubella that typically involves wrists.
Pain of Muscle, Tendon, Bone, Cartilage, Ligament & Blood Vessel is in body of muscle (Charley horse in calf, or sore back) or part that attaches to bone or joint (tendonitis). It is often due to exertion such as too much walking (sole of foot) or from tennis or other sport game in poorly trained person, or in first-time jogger. Sometimes single sudden movement has pulled, stretched or partly torn a muscle. Best is an acetaminophen, and re---lax.
Bursitis and Bursal cysts - Baker's Cyst, Ganglion
Bursa is slippery sac between muscles around joint. Sometimes it gets irritated by constant small traumas, especially on side of upper arm just below shoulder (deltoid bursitis) or around knee (housemaid knee). Symptom is localized soreness with limitation of motion. Money is wasted on cortisone injection (Instead, rub in 0.12% betamethasone ointment after hot shower or bath daily for 1 week). Best is to stop the repetitive activity (baseball pitching, housework) that irritated the bursa, to use elastic band for joint where it is applicable (knee), and also local heat with acetaminophen for pain med.
   Baker's cyst is swelling behind knee from a blood cyst, sometimes after trauma. In worst case may benefit by drainage with needle by experienced physician. One meaning of ganglion is a cyst on back of hand, from bursa fluid and has old remedy of dropping a heavy book on it but best needled by experienced doc and drained. Both types can be left alone forever.
Bone Pain
that you cannot explain by trauma and that lasts should have x-ray. Such pain may be early sign of bone infection or tumor.
Pain over jutting-out point of elbow due to trauma is ‘tennis elbow’ in middle-age man, not necessarily tennis player. It causes soreness and pain over lateral point of elbow and should be treated by elastic band on elbow and acetaminophen for the pain.
Thrombophlebitis - DVT - Pulmonary Embolism
In a leg calf, gives swelling of the one calf and ankle, and point soreness, made worse by standing on toes. Also, especially on standing, you will notice your calf on the affected side is fuller than usual and very hard all over. It is Deep Vein Thrombophlebitis (DVT). If you think you have it, eat an aspirin and get to a University-HMO (Health Maintenance Org, or hospital clinic) for diagnosis and anticoagulation to prevent blood clot to lung. (And see Pulmonary Embolism in Notebooks 6)
Reynaud Syndrome
also known as Reynaud Phenomenon is your fingers becoming hypersensitive to cold - always both hands (if one hand, suspect vascular block in arm) and episodic (coming & going with cold or other irritating stimulus). The fingers blanch and sometimes one finger is worse than others. It usually hits middle-aged persons and makes them anxious about having collagen diseases - lupus, dermatomyositis, scleroderma. The Reynaud Disease is a progressive small artery disease with symptoms like the Syndrome but is progressive  and eventually causes coronary artery disease, strokes and severe migraine. In one case I know, it seems to have led to Parkinson's Disease. This case is c.60-y-o man who has had moderate Reynaud's for 10+ years. He recently reported very good results after switching from a beta-blocker to a calcium-channel blocker (Amlodipin 5 mg/day). He is also taking an ACE-inhibitor (Lisinipril 5mg) and a 10 mg statin pill.
Fibromyalgia
Entered our scene in 1990 a condition of persistent muscle-attachment pain with fatigue and insomnia. In 2000, six-million Americans were said to suffer it. Many appear to develop it after traumatic event: childbirth, accident, surgery, or serious illness. Diagnostic criteria are that when doctor presses one at a time on 18 designated points where muscle, tendon and ligament attach to bone, a fibromyalgia patient feels pain at 11 points or more. Fibromyalgia is controversial but in my experience, real. I got it in the neck and it gives tender scalp headaches. But do not make a big deal of it. Acetaminophen or aspirin works OK, and relaxation periods help.
Whiplash Injury Magic Cure!
Riding in car and its being struck from behind, accelerates the upper body forward, and if the head has no back support it will be jerked backward. This sudden strain causes neck pain. Before lawsuit & workman’s compensation, the whiplash cleared up with no treatment. Today, with large cash award publicized, it lasts for as long as it takes to collect the money. Then it disappears, usually right after a sufferer’s hand touches money. A wonder cure!
The Back and Its Pains  afflict all of us from middle age. Mostly bad posture, too heavy toting, and falls and other accidents.  It is my main affliction now at age 85. The following sections deal with it.
Lumbo-sacral (Lumbago) and Sacroiliac L-S Pain Disc Syndrome
In L-S, often an apparent inciting event (accident, fall, blow to back, unusual lifting and carrying, bending over) occurs and first attack is severe. Thereafter attack recurs, lasts weeks to month, often starts at worst and improves. Chronic trauma and poor postures worsen it. The attacks can recur for life. Here is my many years personal and professional experience: Pain during attack varies and one person during one attack may have more than one type pain. Worst is pain that shoots like lightning from right or left (pain mostly one sided) lumbosacral area down leg and totally causes the victim to be afraid to move. Worst pains start the attack and it improves within 24 hours. At first the patient crawls on hands and knees. By 2nd or 3rd day she is starting to walk. Strong pain medication is needed at first but by 2nd or 3rd day 500 mg acetaminophen (aka Tylenol extra-strength) and local warmth give enough relief to make life tolerable. For the rest of the attack, the pain is dull and localized. When femoral nerve root is affected, pain radiates from backbone area to hip and front of thigh on same side; when sciatic (sciatica), it goes down back of buttock and rear leg to back of heel. Sometimes an attack consists only of low back pain. Whatever type pain, certain movements worsen it. Most typical is pain on standing up after sitting on plushy cushioned sofa. Moderate walking is good and seems to end pain faster. Local heat from shower or bath helps especially for sleep at night. Firm backing of bed mattress, chair and corset is best, and back should always be supported, as in high back chair. Eventually as in my case the pain may become a soreness localized around waist and in front of both hip bones, worst on starting movement and thence improving but quite limiting. Aspirin 325 mg or acetaminophen 500 mg once a day has made my old age low-back-pain life livable. By this time MRI of lumbosacral area may show lumbo-sacral vertebrae collapse and compression fractions. Undoubtedly tension or pressure on the nerve roots or even the lowest part of spinal cord are the essential cause and finally a patient may become completely invalided. Best of all is prevention while young by good posture and avoidance of falls.  Today, for me, an elastic girdle helps much.
 Preventive. Lie on firm mattress flat on back. Do no heavy lifting; lift by placing most tension on knees. (While lifting, keep back straight and lift with knee bend and extension) Be careful bending your back – avoid it as much as possible and do it slow and careful. On long jet flight do not stay in seat for hours. Get up and stroll.
Inter-vertebral disc hernia: Age is important here and it is not what most persons think. Serious herniated discs are most frequent in the age 20's, 30's and 40's when the disc is still gelatinous because at older ages it hardens and may crack but no hernia. The disc involved is mostly between 5th lumbar and 1st sacral (L5-S1), which is low back just above top of buttock cleft. Symptoms typically start after a flexion (bending) or a sneeze, a lurch or other sudden movement though sometime it can’t be recalled. The fully developed herniated or ruptured disc syndrome is pain in sacroiliac region radiating down one side into buttock, thigh and calf; a stiffly bent or unnatural spinal posture; and, in worst cases, pins and needles feeling in bottom of foot to toes with muscular weakness in the foot. Initially shooting pains down back of foot are frequent. MRI is the best test because noninvasive and accurate but even when it shows “bulging disc” or “herniated disc”, there is no reason to rush into surgery. Before decision for surgery, get it confirmed in second opinion by independent expert who should be a neurologist; do not depend only on orthopedic surgeon programmed in favor of disc surgery, his bread and butter operation.
Warning Against Opioids for Back Pain : Today in U.S.A. most back pain is being treated with combination anti-pain pills that contain an NSAID like Tylenol and an opioid like Oxycontin, cf Vicodin  or Percocet.   The opioids do not relieve back pain; they merely create a troublesome addiction.  Use Tylenol alone or other NSAID without opioid. 
Corticosteroid injections into painful joints or back should be avoided. At best they afford sometime temporary relief (More often than not they do not work) and at worst they make complications (Worst case, the recent epidemic of fungal meningitis from corticosteroid injections in back for lumbosacral or disc pains)
Malingerer and Neurotic
Since pain cannot be detected by anyone other than the sufferer, it is not surprising that a person may try to seek gain by faking it. Such case is not difficult for an alerted mind to spot. Always the pain starts suddenly in front of others, appears massive and totally disabling, with moan and groan. Bizarre contortion and posturing may be noted. Almost always the gain from the pain is avoidance of unpleasant or unwanted activity or desire not to pay a bill or the idea to initiate lawsuit.
(For friend or tour guide) Malingerer should not be confronted. Best is to try to satisfy the need, if not unreasonable. More frequent than malingering is backache complicated by neurosis. Sufferer may not be consciously aware of underlying motivation. Usually it is need for sympathy, companionship or love from previously uncaring family member, work superior, or friend. Often it is wish to get out of unhappy responsibility such as being caretaker for elderly mother or father or mothering unruly child. Neurotic backache usually has physical basis, eg, minor accident, but symptom is exaggerated and recovery delayed.
Neurotic backache should not be treated by psychoanalytic interpretation. Rather try sympathy and patience but also to protect her or him from surgery or expensive testing. It is not always possible and such patient remains at high risk for unhelpful, often harmful operation for “disc problem”. 
14. Personal Experiences with Some Joints 
 Headings in order of appearance in the text.
My Cracked Knee
Advice on Knee
Knee Replacement – Personal Vignette
Achilles Heel tendon trauma complicated by shoe
My Cracked Knee: When it comes to knee, I feel what I write. At age 15, I played the football End position. In America, football teams consist of a line with an End lineman on left and right. The End is suited for a slim, speedy lad who races off to a side to catch a football pass thrown by a line backer, and saves the game for his team by fleet-footed, broken-field runs for touchdowns. But my End ended when I leaped up to catch a football and came down hard on right knee. Within minute it was swollen and painful. X-ray showed cracked kneecap. 
  Six months and 2 ankle-to-thigh plaster casts later I finally walked without pain. My knee knitted but it became a magnet for trouble. Unpredictably I have had knee pain and swelling from minor stress from banging or from bad positioning.
Advice on Knee: In absence of accident or sports trauma, a non-discolored, mildly painful or sore knee does not need a physician. But a knee that has snapped, crackled or popped, as well as ripped; that is discolored or badly swollen; or that you are unwilling to bear weight on needs an orthopedist.
Follow up on Me: Now at age 85 my knee has not bothered me for 10 years. Time and age have truly healed what had seemed a major orthopedic problem.
Knee Replacement – Personal Vignette from my late Cousin Lila in her words:
When I was 55 I was told that I needed total knee replacement. I have arthritis, & my knee was swollen, very painful. X-ray showed I had no cartilage, just bone on bone. At that time I did not want the surgery. Every now and then I would get a cortisone shot. I couldn't take anti-inflammatory med. (It upset my stomach too much, I can't take anything that contains aspirin, it makes me throw up)
Finally, after over 15 yrs (I tried every injection series that came out) I decided to have the surgery. It's my right knee, and I couldn't go from the gas pedal to the brake (in my car). I had a hard time going up and down stairs. I had a wonderful surgeon. I had all the workup before surgery, and he had me give 1 pint of my own blood (which I needed during the surgery) I had this done June 19th 2002. I was in the hospital for 5 days then went to rehab for 1 week (where I had 3 times a day for 1 hour therapy). When I went home, a therapist came to the house 5 times a week for 3 weeks. All this time (since surgery) I had a machine that bent my knee. (I had 30 staples, which they took out when I left rehab) Then I went as outpatient, 3 times a week for therapy. They had a treadmill, under water, which made it much easier to walk. For about 2-3 months, it felt as though I had a tight belt just under the knee. I used a walker for 4 weeks or so, & a cane for 1 week. It was a long haul, and at first I didn't think it was worth it, but now I do. I can stand up straight. I can walk. My knee is still a little stiff (It's now 9 1/2 months) and I have to go back the middle of June for my year checkup. It was a very long haul, but I have a better quality of life.”
 Postscript: 2 years later Lila was complaining bitterly about recurrence of her knee pain. The lesson here is that initial satisfying result may deteriorate into failure. Post-postscript: 3 years later, Lila died from cancer. She might well have waited out the desire for surgery. Note that this was knee replacement; my contacts reveal that hip replacement is better than knee for permanent pain relief and resuming natural gait.(But note the much better results with hip-joint replacements as described in previous chapter)
Achilles Heel tendon trauma complicated by shoe
Several years ago someone bought me a new pair of shoes. They were a hard leather-like shoe. One day, I had to attend a funeral and having no formal shoes decided to wear the gift pair just the few hours. A day or so later I began to notice soreness and swelling over and around my right heel tendon and it worsened over next days so much I almost could not walk. I had the foot x-ray'd. It showed a 1 cm diameter calcification at lowest part of the muscle that forms the right Achilles tendon. My joint doctor explained it was old trauma calcification and, because of the hard back-edge irritation due to the gift shoe, it had swollen and become tender. He advised no treatment except avoiding trauma. I used acetaminophen. It cleared up.  Several years later I got a recurrence due to stretching my leg out from a chair. The pain subsided over a week, helped by acetaminophen, I stopped putting my feet up in that away from that moment on and since then have been fine.
There is a lesson here beyond avoiding trauma and beside being careful to wear comfortably fitted shoe. Avoid strong treatment (like arthroscopy or other surgery to remove an irritating calcification) and give magnificent neglect a good college try helped by acetaminophen.(But do not let that prevent important surgery like hip-joint replacement)
Neck: Everyone is going to have a problem with neck sprain some time during life, either from motor vehicle accident or poor posture. A Cervical collar for a week or two should solve the problem. Except for severe trauma the neck bones should not be a serious source of worry. In general MRI and CT of chronic neck discomfort tend to be over-interpreted and unless definite fracture or dislocation or cervical disc symptoms, abnormal findings should be sat on and treated with the famous remedy: tincture of time or also called Do nothing until it gets worse.
 Advice on posture and position is: while walking, look up and straight ahead mostly and occasionally glance at ground for obstacles. Watching TV or computer screen, take breaks where you gaze into distance. or just lie down on back with head extended.

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